Pastors as gatekeepers

Pastors as gatekeepers: Congregational encounters with mental health and substance abuse issues

Clergy have a valuable role in helping those facing the challenges of mental health and addictions issues.

Curtis J. VanderWaal, PhD, is chair and professor of Social Work at Andrews University and director of the Center for Community Impact Research at the Institute for Prevention of Addictions, Berrien Springs, Michigan, United States.

Andrea Opel, MSW, is a child and adolescent social worker in Elkhart, Indiana, United States.

Edwin I. Hernandez, PhD, serves as provost of the Adventist University of Health Sciences, Orlando, Florida, United States.

The vocation of a pastor is to care for the spiritual needs of a congregation and community. However, as many clergy know well, pastoral care is multifaceted and complex. For example, one of the hats that pastors frequently wear is that of pastoral counselor. Although pastors have traditionally offered support and pastoral care to congregants, they are beginning to spend more hours counseling both congregants and community members. One study indicated that pastors were spending time in pastoral counseling equivalent to that of marriage and family therapists in private practice.The same study showed that pastors are encountering persons and families experiencing mental health and/or addiction challenges more frequently than they have in times past. These trends indicate that the needs of congregations, and the broader community, may be shifting. As these needs shift, so does the role of the pastor.

Unmet needs

Mental health and addiction problems are becoming increasingly common and widespread. The United States has the highest rate of mental health and substance abuse disorders among developed nations.2 Many who struggle with a mental health disorder also have co-occurring substance abuse or dependence. Unfortunately, most do not receive treatment. A Substance Abuse and Medical Health Services Administration (SAMHSA) report shows that, in 2010, only 11.2 percent of individuals with a mental health or substance abuse disorder received treatment.3 Others did not seek treatment, did not have medical insurance or assistance to pay for treatment, or were concerned about the stigma. The percentage of individuals who do not receive treatment is even higher among ethnic minority groups.4

It is no coincidence, then, that as the number of experiences of mental health and substance abuse problems rises, the time clergy spend caring for these needs also rises. Although many do not seek treatment, those who do often contact their clergy. In fact, clergy may be contacted more often than psychiatrists or general doctors, and over half of those who seek help from clergy do not contact other providers.5

A quick look at pastors’ weekly activities would likely illustrate how pastoral care and counseling are prominent roles in their ministries, and rightly so. Pastors are perceived as trustworthy and caring helpers, often even by people who are not members of their congregation. Pastors are able to build valuable long-term relationships with individuals and families, which fosters trust. Further, these relationships allow pastors and clergy to notice changes or distress in their congregants’ lives and offer help. Pastors are also more accessible. As stated above, many individuals do not seek treatment due to costs and the stigma of mental health treatment. Yet seeking help from a pastor is usually free, is more comfortable, and holds far less stigma.

A survey and its results

The experiences of pastors serving individuals with mental health needs and the indications of previous research highlight the connections between pastors/clergy and mental health treatment providers. An email survey, sponsored by the DeVos Family Foundation and conducted by the Center for Community Impact Research at Andrews University, focused on these issues. There were 215 pastors and clergy in Kent County, Michigan, from more than 50 different denominations who responded. The survey asked these ministers about their knowledge of mental health issues, how often they encountered congregants who were experiencing mental health or substance abuse challenges, their willing­ness to refer to or work with treatment professionals, and how often they had made referrals to mental health services.

What follows is a summary of the findings from this survey and implica­tions that these finding bring to the role of pastors in mental health care.

The 215 pastors who responded to the email survey were most likely to be male (88 percent), be more than 50 years old (59 percent), be well educated (72 percent had a master’s degree or higher), and have had experience (75 percent having served for 11 or more years in ministry). Pastors’ ethnicities roughly reflected the county population (67 percent Caucasian, 16 percent Hispanic/ Latino, and 12 percent African American). The denominations represented also reflected the county population. There were more pastors (35 percent) who were from the Reformed tradition. Other respondents were Evangelical, Pentecostal or Charismatic, Catholic or Orthodox, and other Christian traditions such as mainline Protestant.

Pastors’ understanding of mental health issues

Figure 1 shows how pastors under­stand the causes and challenges of mental health problems. A large majority (86.4 percent) of clergy believe they can recognize a serious mental health crisis. Almost two-thirds (63.2 percent) understand that church members often prefer clergy help and support more than they do the formal mental health community. Most clergy (74.7 percent) favor a biological or physical explanation for serious mental illness. As such, they are usually (88.2 percent) supportive of medication usage and do not think church members are imagining their symptoms (81.6 percent) or are lacking in faith (85.2 percent). This recogni­tion often translates into a referral to a mental health professional when the issue becomes serious. However, more than one-third of clergy (37.3 percent) believe that individuals experiencing serious mental health challenges could be possessed by demons. Though the phrasing of this question is somewhat ambiguous, it does highlight an area where further education and study would be helpful, in understanding both the sources of severe mental health symptoms and demon possession.

Figure 1: Pastors’ understanding of mental health issues.



 Not Sure






I can recognize a person with a serious mental health challenge




I believe that persons with a mental health challenge are often imagining their problems.




I believe there is a biological or physical basis for mental health challenges.




I would encourage a church member to stop taking medication for a mental health challenge in favor of seeking spiritual healing.




I believe that a church member often lacks faith when they are going through a mental health challenge.




I believe that persons with a serious mental health challenge could be possessed by demons.




I believe church members usually feel more comfortable receiving pastoral counseling than going to a mental health professional.




Pastors’ encounters with mental health and substance abuse issues

Pastors say that they regularly encounter serious and challenging men­tal health and substance abuse issues. On a weekly basis, pastors generally help with marriage and family problems (42.7 percent), mental health challenges (31.4 percent), and substance abuse problems (26.5 percent) most frequently. Although incidents of violence (9.3 percent) or sexual abuse (3.5 percent) are reported less frequently, these challenges are often more intense and have a signifi­cant impact on a family or community, which can trigger other mental health issues. Furthermore, the experience of substance abuse and violence is more prevalent in ethnically diverse com­munities that often experience greater economic challenges.

The survey also asked respondents to state the number of referrals they had made to a mental health or substance abuse counselor within the past six months. Figure 2 shows that almost half (47 percent) of the respondents reported making 1 to 5 mental health referrals within the past six months, and 7 percent reported referring 6 or more people to a local mental health center. More than one-third (40 percent) reported making 1 to 5 referrals for substance abuse or drug treatment, 8 percent reported having referred between 6 and 10 people, and 3 percent reported making 11 or more referrals in the past six months.

Figure 2: Frequency of referrals to a substance abuse or mental health counselor


Substance Abuse Referrals

Mental Health Referrals

More than

20 persons























Pastors’ referral choices for mental health problems

As seen in figure 3, when clergy were asked how they would handle a church member with a serious mental health challenge, almost all pastors (94 percent) said they would be likely to make a refer­ral to a mental health counselor. About two-thirds of the surveyed pastors said they would be likely to make a referral to a medical doctor, with less than half likely to make a referral to an emergency room. The variation in these responses, combined with one-third of clergy who responded Not Sure shows that pastors likely wish to consider the nature of the problem before deciding where to refer their church member. Very few of the pastors said that they would offer prayer and spiritual counseling only, indicating that most pastors understood the limits of sometimes narrow spiritual solutions to serious physical and mental problems.

However, the decision about which issues were necessary to make a referral depended largely on how comfortable the pastor felt in handling the situation. Between 80 and 90 percent of pastors were likely to make referrals for issues that they viewed as more serious in nature, such as depression, nervous breakdowns, domestic violence, sexual abuse, and alcohol/ drug addiction (no graph provided). They likely recog­nized these issues as often being beyond their scope of training and expertise; thus, they are willing to send church members to mental health professionals for further help. Willingness to refer dropped to about 50 percent with issues relating to anxiety, marital relationships, anger, parent­ing, and adjustment to life problems. Such a reduction likely reflects what clergy might consider to be less serious problems that they can more often handle without outside assistance. Issues considered to be least serious, including racism/discrimina­tion, financial difficulties, or problems at work, are least likely to be referred for counseling (less than one-third), pos­sibly again reflecting clergy willingness to comfortably counsel these persons.

Figure 3: If one of your church members or persons you know was experiencing a serious mental health challenge, how likely would you be to do the following?



Not Sure






Give them prayer and spiritual counseling only.




Refer them to a hospital emergency room.




Refer them to a medical doctor.




Refer them to a mental health counselor.




Refer them to another pastor who has more training and experience.




The pastors surveyed expressed that they do encounter mental health and substance abuse issues that are beyond their comfort and training level. For example, pastors may not be adequately trained to recognize the symptoms of mental health problems, addictions, and especially abuse. Rarely do pastors have opportunity for intensive training in counseling and treatment methods that would be most helpful in these situations.

Pastors’ perceptions of mental health professionals

As seen in figure 4, the large majority (91.3 percent) of pastors expressed will­ingness to consult and even collaborate with mental health professionals (95.4 percent would make a referral to a mental health professional if necessary), both within and outside of their churches. Most (87.7 percent) are willing to allow mental health professionals to present seminars or lead support groups (81.7 percent) in their churches. More than two-thirds (68.2 percent) are willing to collaborate on community service outreach projects, and half (51.4 percent) are even willing to allow a mental health professional to have an office within their church. These findings show that pastors are generally open to working with counselors and value their expertise.

Survey results also show that ethnic background and religious tradition play important roles in the referral decisions of some clergy (no graph provided). While most Caucasian pastors (82.8 percent) do not feel a need to consult with a counselor of the same ethnic background, about half of all Hispanic/Latino and African American clergy prefer this opportunity. African American and Hispanic/Latino pastors are also significantly more likely than Caucasian clergy to prefer that a counselor share a similar denomina­tional background. Further, a very large majority of Evangelical, Reformed, and Pentecostal or Charismatic church clergy feel it important to make a referral to a Christian mental health professional. This issue is substantially less important for Mainline/Other Protestant and Catholic/ Orthodox clergy. The significance of the ethnicity and religious tradition of a preferred counselor or treatment pro­fessional for these groups reflects the importance of cultural competence in mental health treatment.

Figure 4: Pastors’ perceptions of mental health professionals.



Not Sure






I would welcome the invitation to work together on a community service outreach project with a mental health professional.




I would allow a mental health professional to have an office in my church.




I feel my role as a pastor or leader would be compromised or devalued by the involvement of a mental health professional within the congregation.




As a pastor, I would consult with a mental health professional about a church member’s mental health issue.




I would consider making a referral to a mental health professional when the circumstances are beyond the scope of my knowledge and/or expertise.




I would prefer consulting with a mental health professional who is the same ethnicity as me.




I would allow a mental health professional to present a seminar in my church.




I would allow a mental health professional to lead a support group in my church.




A call for creative ministry

Mental health and addiction chal­lenges are a growing reality that calls for creative ministry responses. The pastors who participated in this survey find encounters with mental health and substance abuse issues are a common part of their ministries. Most also have a basic understand­ing of the causes, symptoms, and appropriate treatments. The frequency and scope of challenges that pastors encounter provides evidence of the value and trust that congregants place on clergy as helpers. Ministers are an impor­tant presence in the community and in the lives of congregants, a presence that reaches well beyond spiritual leadership.

Because of the unique role that pas­tors play in a congregation, they have significant opportunities to help with mental health and substance abuse challenges in ways not open to other counselors. For example, pastors provide a no-cost, safe space for counseling that is more accessible for many than professional treatment services. Clergy are also in a position to help diminish the stigma and discrimination surrounding mental health and addictions issues. In addition, they can provide a welcoming space for individuals and families to share their struggles and victories of the healing that can happen through professional treatment, as well as through prayer and spiritual guidance.

A call for connection and collaboration

The results of this survey also affirm the growing necessity of stronger con­nections between clergy and mental health treatment professionals. Most of the pastors surveyed recognized that the mental health and addiction issues they encounter are rooted in causes that extend beyond faith and spiritual problems. They also indicated a willing­ness to refer congregants to a treatment professional, particularly for issues like depression, anxiety, sexual abuse, vio­lence, or a nervous breakdown. The willingness of pastors to connect with treatment professionals through referrals and other collaboration reflects a grow­ing openness in ministry. Because clergy often do not receive the level of training needed to appropriately help with these challenges, mental health and substance abuse treatment professionals, particu­larly those who are Christian, can provide an important resource to congregations.

A stronger relationship between pastors and treatment professionals will strengthen the ministry of both fields. For example, pastors and treat­ment professionals could collaborate on training to improve treatment and assessment skills for both mental health and spiritual needs. This collaboration could also enhance cultural competency in both fields when dealing with dif­fering ethnic and religious traditions. Many pastors also find it helpful to develop a network with trusted Christian counselors for referral purposes and to advise on appropriate treatment deci­sions. Furthermore, pastors can connect with mental health and addiction treat­ment professionals to teach a seminar, facilitate a support group, or conduct screenings at their church. Similarly, congregations have an opportunity to partner with community services by inviting mental health professionals to have an office in their church or be included in a ministry team. Finally, some churches may wish to provide a part-time or full-time in-house Christian counselor or offer financial support to help congregants afford mental health and addictions treatment programs.


Mental health issues, addictions, family and relational conflicts, and abuse are, unfortunately, part of our experience as humans in community. Clergy have a valuable role in helping those faced with the challenges of mental health and addiction issues. Furthermore, the regu­larity with which pastors encounter such challenges shows evidence of the deep connection between spiritual and mental health needs. Pastors and community treatment professionals are hearing a fervent call to work as partners with the same mission, rather than in two sepa­rate realms. The gifts of all are needed to join God’s work of bringing whole­ness and healing to those in need.

1 Michelle Thomas, “The Interprofessional Collaborative Practice: Clergypersons and Mental Health Professionals,” Pastoral Psychology 61, no. 1 (Feb. 2012): 99–112, doi:10.1007/s11089-011-0408-x.

2 WHO World Mental Health Survey Consortium, “Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization,” American Medical Association 291, no. 21 (2004): 2581–2590.

3 Substance Abuse and Mental Health Services Administration (SAMHSA), Results From the 2010 National Survey on Drug Use and Health (Rockville, MD: Department of Health and Human Services, Office of Applied Studies, 2010), /nsduhLatest.htm.

4 Harold Neighbors et al., “Race, Ethnicity, and the Use of Services for Mental Disorders: Results From the National Survey of American Life,” Archives of General Psychiatry 64, no. 4 (April 2007): 485–494, doi:10.1001/archpsyc.64.4.485.

5 Philip S. Wang, Patricia A. Berglund, and Ronald C. Kessler, “Patterns and Correlates of Contacting Clergy for Mental Disorders in the United States,” Health Services Research 38, no. 2 (April 2003): 647–673, doi:10.1111/1475-6773.00138.

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Curtis J. VanderWaal, PhD, is chair and professor of Social Work at Andrews University and director of the Center for Community Impact Research at the Institute for Prevention of Addictions, Berrien Springs, Michigan, United States.

Andrea Opel, MSW, is a child and adolescent social worker in Elkhart, Indiana, United States.

Edwin I. Hernandez, PhD, serves as provost of the Adventist University of Health Sciences, Orlando, Florida, United States.

April 2015

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